HomeMy WebLinkAbout1245 Lincoln Ave - Special Inspections/Combustion Safety - 09/19/2017I
F®_ Collins.
A.
..:.a:tuLy ut;ttEtOt�rri�rif
281 N. College Ave.
PO Box 580
Fort Collins. Co
970A16.2740
970.224.6134 (fax)
kcgov coWdevefopment
Combustion Safety Test Compliance Form .
Ra Ircnment of Natural Draft Appliances in Eai5uug houses
Address: _ 1 CVI , � `7 /-3 Permit #
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fc
Technician•Nama i
Technician Signati
Appliance Tested:
Appliance Replaced: � � � is to ( /
Spillage Duration (in second5�: .Z
Pass L/ Fail
Carbon Monoxide (parts per million):
Date Tested:
Natural Conditions:
Spillage Duration t6 seconds): _ Carbon Monoxide (parts per million): 4--
Pass Fail Date Tested.• 9
(wiled test requires corrections until test passes under Ariwral ConJWons)
Technician's recommendations to correct tested appliance failure:
t'NLVM Y�1{lDIL.AJGI+U�21t111UI1.J.
I eerfify that I am the legal owner of the above listed property and hereby acknowledge that my appliance
has fatted a Combustion Safety Test under worst -can conditions. I acknowledge that I have received a
.�.vs..�.��:wuvu �Yiiuiw aiaiKj� iui�iiva4llUi1 D11GGL
Owner's Name (print)
Owner's Signature
CSTxeptacement/mfural draft/4 75.I2
Date
L/